435202351-4-25-2023-26-AS-DMAO-CR933P-20230425175353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202351
Report Date: 04/25/2023
Date Signed: 04/25/2023 05:54:03 PM

Document Has Been Signed on 04/25/2023 05:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	BELMONT VILLAGE SUNNYVALE		FACILITY NUMBER:	435202351
ADMINISTRATOR:	LOLA BULLOCK		FACILITY TYPE:	740
ADDRESS:	1039 E EL CAMINO REAL		TELEPHONE:	(408) 720-8498
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	150	CENSUS: 129	DATE:	04/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lola Bullock		TIME COMPLETED:	06:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Trang Pham and David Marrufo, arrived unannounced to conduct an annual required one year inspection. LPAs met with Lola Bullock, Administrator. LPAs toured the facility inside and outside including the independent living, assisted living and memory care units. LPAs toured the common areas, kitchen, dining room, main courtyard, 9 bedrooms and 4 bathrooms. LPAs also inspected the outside storage area and attic which has emergency supplies, butane tanks, tools, cleaning supplies, all secured. 9 out of 9 residents' bedrooms inspected were observed to have functioning emergency pull cords. The signal system was tested and observed to be operating normally. Soap and paper supplies were observed to be available in the 4 observed bathrooms. LPAs tested the water temperature to be 117-118 degrees Farenheit in 4 bathrooms. Facility has functioning key pad system in the memory care unit. LPAs inspected the facility's kitchen, refrigerator and freezer. Cut food was observed to be sealed and ready. Prepared food was covered with preparation date written on lid. Pantry was observed to be stocked with at least 1 week's supply of non-perishable food and a perishable food supply of at least 2 days. LPAs observed that rooms are equipped with fire alarms and carbon monoxide detectors. Fire extinguisher observed to be last inspected in July 2022. During inspection of the memory care unit, LPA noted that there were 3 scissors in the bathroom cabinet for resident R1. LPA informed Administrator who removed and secured scissors in a locked cabinet. See LIC809-C for more information. Page 1 of 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
	VISIT DATE: 04/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPAs reviewed the centrally stored medication log for 9 out of 9 residents and found them to be complete.

LPAs reviewed 7 residents' records, and 6 of the residents whose records were reviewed had dementia. 5 out of the 6 residents with dementia had physician's reports that were over a year old and outdated.

LPAs reviewed 5 staff records. Staff S1 and S2 had expired first aid certifications.

LPAs reviewed the fire drill report. The last drill was conducted on 3/23/2023. The facility records show the last annual fire alarm equipment test was conducted on 6/13/2022.

A Technical Advisory note was issued. See LIC9102 for more information.

Deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with Administrator Lola Bullock. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 04/25/2023 05:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BELMONT VILLAGE SUNNYVALE	FACILITY NUMBER: 435202351
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: During record review, 5 out of 6 residents with dementia whose records were reviewed did not have a physician's report that was updated annually, which poses a potential safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	During record review, 5 out of 6 residents with dementia whose records were reviewed did not have a physician's report that was updated annually, which poses a potential safety risk to residents in care.
	POC Due Date: 05/02/2023
	Plan of Correction
1 2 3 4	Licensee agrees to review all physician's reports for residents with dementia and schedule appointments to update their physician's reports as needed by POC date. Licensee agrees to submit updated copied of R2-R6's physician's reports once they are updated to CCL.

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on review of staff records, 2 out of 5 reviewed staff did not have current First Aid Certifications, which poses a potential safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Based on review of staff records, 2 out of 5 reviewed staff did not have current First Aid Certifications, which poses a potential safety risk to residents in care.
	POC Due Date: 05/02/2023
	Plan of Correction
1 2 3 4	Licensee agrees to update S1 and S2's first aid certifications and submit copies of the updated certifications to CCL by POC date. Licensee also agrees to audit all staff first aid certifications to ensure that all staff have updated first aid certifications. Licensee agrees to submit a Proof of Correction Statement by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4